WentzMiller Global Services, LLC

Global CME/CPD Newsletter

Keeping Up Around the World

November-December 2013

Dear CME/CPD Colleagues,

What will the impact of Sunshine Acts be on the CME world? The answer is not yet clear -- other than more paperwork for some providers. But what we report in this issue indicates that financial conflicts of interest do result in bias and in prescribing behavior changes by physicians. Will the new transparency requirements reduce this effect? What is your opinion? Share your insights and write me at Lew@wentzmiller.org.

Over half the 334,000 physicians in the study sample received payment of some kind (meals, travel, speaking fees)

Doctors are more likely to prescribe a drug of the firm that pays them

The larger the payments, the greater the increase in prescribing the paying firm's product

On average, a payment from a pharmaceutical company to a physician leads to 29 more Medicare prescriptions per year; this rises to nearly 100 if the payment is $1000 or more. The increase applies even when there are generic equivalents available, the authors note. In states with little corruption as measured by federal conviction rates for such crimes (Minnesota, Oregon, Nebraska), "the prescription payment magnitude is cut by 50%" compared to the states with most corruption (Louisiana, Mississippi, Illinois). And women, they said, are "more honest and less corruptible than men"!

We wonder how the data would compare with practices in the rest of the world. We note that in India, which is a country with considerable corruption, the Medical Council of India specifies that "a medical practitioner shall not receive any gift from any pharmaceutical or allied healthcare industry", which includes travel, hotel, or cash. However, a medicolegal commentator in India states that the regulation "apparently permits some of these gifts to be channeled through an association or institution."

Which affects CME more: COIs or bias?

Do conflicts of interest (COIs) always result in undue influence and bias? Not always, say the authors of "What Is the Enemy in CME, Conflicts of Interest or Bias?" in a recent issue of JAMA. CME providers "need to give greater attention to identifying and reducing bias," they say, in addition to identifying COIs. They define bias as "presenting information, drawing conclusions or making recommendations that are not scientifically valid or not supported by the weight of rigorous evidence".

They propose four key questions that CME providers can use to screen for bias. Learners seldom report very little commercial influence or bias, the authors state but "probably underestimate bias for lack of knowledge or lack of incentive to comment."

The Sunshine Act has an international reach

The US Sunshine Act broadly applies to both domestic and foreign drug and device manufacturers that operate in the US, reports a major Texas law firm. Therefore those companies "will need to prepare to collect and report data about their interactions with US physicians anywhere in the world."

Even physicians who practice exclusively abroad will probably be included so long as they maintain US licenses. CME providers around the world will now be asked by commercial supporters to provide data on gifts, including meals, travel, speaking fees and the like, given to any US physicians attending their programs, if the companies themselves do not maintain full records. Pfizer has already informed its subsidiaries, who in turn are notifying providers.

And companies that operate in the US cannot circumvent reporting by paying doctors indirectly through their foreign entities. All data must be reported back, say the lawyers.

Lisa Sullivan, a WentzMiller associate based in Singapore, and several other speakers warned attendees at the annual congress of the International Congress and Convention Assn. (ICCA) in Shanghai of the impending impact of Sunshine Acts on their venues around the world. The session addressed the question:

Can international healthcare meetings evolve swiftly enough to meet the pressures to become more transparent, more educationally effective, and still remain financially viable?

The American Society of Clinical Oncology (ASCO) has released a new policy that bans authors from submitting meeting abstracts or journal articles if in the previous 2 years, they have participated in a speakers' bureau for the company sponsoring their research or had an employment relationship with the company. Critics feel this will substantially reduce submissions of original research.

European and US accreditors of CME/CPD met recently in Cologne, Germany, to discuss "Decisions in CME/CPD Accreditation." The Union of European Medical Societies (UEMS) has a reciprocal credit agreement with the American Medical Assn., but interestingly, the AMA was not a sponsoring organization along with UEMS. Instead, the US was represented by Murray Kopelow, head of the Accreditation Council for CME (ACCME). Does this suggest UEMS may move to accredit providers instead of programs, as does ACCME?

CME providers in the US have been wrestling with ways to integrate their programs, particularly performance-improvement CME (PI-CME) with the requirements specialists now have for Maintenance of Certification. A major hospital, National Jewish Health, has now done so in cooperation with the American Board of Pediatrics, says a MeetingsNet report.

CME opportunity: doctor-patient interactions

Shared decision making with patients was a major topic at this year's Global Alliance for Medical Education (GAME) conference in Barcelona.

Now a new study in the US shows that 64% of men interviewed about interaction with their physicians on the need for PSA screening reported no such discussions on the topic. The authors said that "shared decision making needs to be improved in decisions for and against PSA screening."

Two UK universities suggest in a new report that a minority of senior healthcare workers across 5 countries exhibit poor professional standards, contributing to a decline in patient care.

These workers are serving as mentors for medical students, making their lapses worse. These include talking about patients inappropriately, breaching confidentiality and allowing students to practice on patients without valid consent.

Is there room in CME for programs that can change ethical behavior?

ExpandYourMarket

WentzMiller Global Services is pleased to report the addition of two Associates in Mumbai, India -- the brothers Parekh. Dr. Bharat Parekh is a radiologist in Mumbai; he is past chairman, Indian College of Radiology & Imaging, and creator and administrator of the radiology educational web portal, www.edurad.com. Dr. Ramnik Parekh, a family physician, has been president of the Federation of Family Physicians' Associations of India and the General Practitioners Association - Greater Bombay; he is CEO of an occupational health provider and on the board of a health management services company.

We are pleased to announce that our longtime Associate in Italy, Dr. Alfonso Negri, now holds the rank of Senior Associate, in recognition of his outstanding contribution as a consultant to WMGS clients! (He is currently consulting in Japan.)What is changing in your CME world? Share your insights and write me at Lew@wentzmiller.org.

What do you know about online physician networks?

More than 2 million doctors worldwide participate in online communities that provide a mix of these services: medical news, continuing medical education, discussion forums, promotional programs, job opportunities -- and in particular, the chance for doctors to get paid to participate in market research programs, usually for the benefit of pharmaceutical and medical device companies. Most sites continually monitor their activities to produce marketable data.

One major global organization, Networks in Health, has 18 partners in North America, South America, Europe and Asia. A full list can be found on the organization's website. No US organization is a partner, but several US companies are active in the field, some expanding with an influx of venture capital. These include QuantiaMD, Sermo and MDLinx.

Felix Rademacher, CEO of coloquio in Germany, says "4 out of 5 members are open to interacting with industry" and welcome pharma know-how to improve healthcare outcomes. David Schmeier, vice-president of mdBriefCase in Canada, speaks of "big adoption by pharma of the sponsorship of online CME services" created independently by his company. He urges brand managers in other countries to do likewise, because the network sites "can demonstrate effective changes in behavior ... something you can't say about any other medium."

Should the CME community worldwide be tapping into these networks as a way to reach more physicians and to identify learning gaps? Or is the risk of conflict of interest too great?

Why and how pharma bribes Chinese doctors

In a 2011 Chinese Medical Doctor Assn. survey, 95% of doctors said they were underpaid. Monthly pay ranges from $470-$1,250, according to McKinsey & Co. Is it any wonder that some doctors accept "speaking fees" of $320 or participate in high-cost "educational" junkets in China or elsewhere in the world -- in exchange for prescribing specific drugs? These data were reported in a recent Wall street Journal article.

Repeated allegations of bribery are now involving many foreign and domestic pharmaceutical companies, including GlaxoSmithKline, Eli Lilly, AstraZeneca, sanofi, Novartis, Novo Nordisk and UCB. "The severity of these incidents" has prompted investigations by the State Administration for Industry and Commerce and the National Development and Reform Commission as part of the new government's efforts to stamp out corruption, says one report.

The scandals are making an impact on legitimate CME providers both in China and elsewhere. A visit by leading Chinese gynecologists to learn about techniques in endometriosis surgery at a well-known European center was suddenly canceled; the Chinese organizer said that the health departments and hospitals in most provinces have notified doctors that foreign exchange activities have been suspended for the near future.

Now the US Department of Justice is trying to determine if Glaxo violated the US Foreign Corrupt Practices Act (FCPA), says pmlive. Unfortunately, inappropriate "physician incentives" are not new in pharma-doctor interactions. Junkets were common in the US and other developed countries until regulations intervened. Companies have been fined repeatedly for bribery under FCPA and other laws. It makes it difficult for medical education leaders in the same companies to uphold standards of independence in their funding of CME.

Europe adopts "Sunshine"; Pfizer US gets tough

Not to be outdone by Sunshine Acts passed into law in the US and France, the European Federation of Pharmaceutical Industries and Assns. (EFPIA) has adopted a public disclosure code that will apply to national codes in 33 countries, and therefore to member companies. A pmlive report says that data collection will start in 2015 for disclosure in 2016; UK and the Netherlands have already started.

Codes will vary from country to country, but all will require the name and address of the healthcare provider (HCP), the amount of payment and details of the sponsorship. The report suggests that data will be reviewed by, among others, US and UK law enforcement agencies, competitors seeking information on relationships with HCPs, and potential whistle-blowers.

In the US, the Pfizer department for independent grants announced that CME providers can no longer use grant funding for food or beverage at any CME event -- or even at a planning meeting.

In brief: Project Globe report - Another misuse of CME - Integration of social media in CME - iPACME

In an unpublished paper, Project Globe Consortium for CPD reports the success of a blended web-based course to improve management of cardiovascular risk factors in primary care practices in Venezuela. Improvements were measured both in cognitive aspects of physician behavior and in reduction of lipids and blood pressure among their patients.

ISTA Pharmaceuticals Inc., has pled guilty in Federal Court to conspiracy to introduce a misbranded drug into interstate commerce and agreed to pay $33.5 million to settle the case. The evidence showed that CME programs were used to promote Xibrom for uses not approved by the FDA and that the company was paying physicians to use the drug.

A report from ArcheMedX describes research that shows how social media can be used in CME. The most common uses were promoting learner engagement, gaining feedback, and collaboration and professional development. Major issues: technology, variable learner participation and privacy concerns.

The International Pharmaceutical Alliance for CME (iPACME) has just been granted member section status by the Global Alliance for Medical Education (GAME). Its purpose is to "ensure quality medical education internationally, promote the value proposition of industry involvement, and to share best practices".

Russia: A need for balanced, relevant online CME

There are many unmet needs for balanced and relevant medical education in Russia, says one author, and pharma should step up to support it.

"In Russia we have 9 time zones," she notes, which makes online education of value to doctors who can't attend conferences. It's a "huge opportunity" for pharma to support high quality education, she concludes.

"Increased adherence leads to overall reduction in healthcare costs in America," according to an industry public policy leader. Joe Ganley says government data show that Rx non- adherence accounts for about 13% of total healthcare expenditures.

Can CME providers find ways to reach doctors and their patients with creative content that will change behavior and keep patients healthier?

ExpandYourMarket

WentzMiller Global Services has principals and associates who are knowledgeable about CME/CPD opportunities and limitations around the world. We have helped medical specialty societies, medical education companies and pharmaceutical companies to extend their resources in the field effectively and efficiently. The results: Improved quality of health provider education, improved reach to new markets and improved care to patients.

This issue has a slightly new design and shorter articles. Hope you like it. We encourage you to submit items about changes or research in the field in your region of the world. Just write me at Lew@wentzmiller.org.

Europe moving toward coordinated CPD, eHealth

The European Commission (EC) has its sights set on more coordinated, cooperative approaches to continuing professional development (CPD) and to improved health care through eHealth. In a recent presentation to the Assn. of the BritishPharmaceutical Industry (ABPI), Dr. Edwin Borman, secretary general of the Union of European Medical Societies (UEMS), reported that the EC is seeking development of a report with these objectives:

1. To provide an accurate, comprehensive and comparative account of CPD models, approaches and practices for health professionals and how these are structured and financed in the EU-27, Croatia and the EFTA/EEA countries.

2. To facilitate a discussion with policy-makers, regulatory and professional bodies to share information and practices on the continuous professional development of health professionals and to reflect on the benefits of European cooperation in this area.

And in a recent meeting in Dublin, Neelie Kroes, EC vice-president for digital agenda, said that the EC eHealth Action Plan is designed to promote new health tools, treatments and systems across the region, including a strengthened evidence base on eHealth effectiveness. This has huge potential to help Europe cope with chronic disease management in its aging population, she said.

Quick report on GAME 2013 in Barcelona

What did participants learn at the 18th Annual Conference of the Global Alliance for Medical Education (GAME) held in June in Barcelona? Highlights follow:

The value of shared decision making, involving staff and patients -- and opportunities for cross-professional accreditation

The World Health Organization's new initiative to improve patient safety in every country -- has CME kept pace?

India's path to a CME system (and GAME Board discussion regarding a meeting there in the future)

Training of primary care clinicians in Mexico in techniques of motivational interviewing

Rollout of a blended learning program on gastro-esophageal reflux disease (internet and live sessions) across 5 Latin American countries

Presentations are expected to appear on the GAME website for members only.

Sunshine Acts going global

France's Sunshine Act has recently been implemented, requiring companies to report, among other disclosures, hospitality costs for healthcare providers at meetings, speaker fees, and any benefit in cash or kind exceeding 10 euro.

The European Society of Cardiology has expanded its education program to patients with the launch of AFib Matters for patients with atrial fibrillation. ESC says that AF affects 6 million across Europe, and is on the rise.

The International Pharmaceutical Alliance for CME (iPACME) has just been created to "ensure quality medical education internationally, promote the value proposition of industry involvement, and to share best practices". iPACME is seeking member section status with GAME. Co-leaders: Dale Kummerle (BMS), Dorian Readnour (Biogen Idec) and Frank Skopowski (Merck).

Certification of global medical meetings managers is moving ahead under the aegis of the Convention Industry Council. One content expert says the exam will probably "have a global scale" without "so much emphasis on CME that someone in pharma wouldn't be able to pass it".

A major US hospital is showing results from using the American College of Surgeons National Surgical Quality Improvement Program. Quality is now rated "exceptional", with a low rate of postop complications. In turn, length of stay has dropped, as has the readmission rate. And costs are lower.

Does CME save millions in healthcare costs?

That is what a US CME company reports, based on a hypothetical analysis of cost savings if doctors applied lessons from a CME course designed to reduce complications of cardio-thoracic surgery.

Looking at outcomes, the authors predicted that for every complication avoided after cardiologists took the course, costs should be cut by a mean of $1.5-2.7 million.

Consider a redesigned system of health care and professional education to improve patients' experiences and population health while cutting costs.

That's the proposal of a Macy Foundation task force. The key: Connect practice redesign with interprofessional education reform, working collaboratively with patients, families and communities. All cutting edge ideas that are in embryonic stages. How can CME/CPD play a leadership role?

ExpandYourMarket

WentzMiller Global Services has principals and associates who are knowledgeable about CME/CPD opportunities and limitations around the world. We have helped medical specialty societies, medical education companies and pharmaceutical companies to extend their resources in the field effectively and efficiently. The results: Improved quality of health provider education, improved reach to new markets and improved care to patients.

The National Health Service of the UK has launched a new plan to "get the best possible value in patient outcomes from every pound spent," says Sir David Nicholson, chief executive. He announced a new clinically-led, local commissioning system to enable patient-centered improvements. "We must all strive to design and deliver care based on the needs and choices of each individual patient," Sir David tells NHS doctors and other healthcare providers.

Something is missing, suggests Prof. Davinder P S Sandhu, postgraduate dean and head of health education South West-Severn Deanery, UK. "We can applaud the focus on good patient outcome," he says. "My worry is in a cash-strapped economy, education budgets get the greatest hits; this year is no exception. We need a well-trained workforce that has the correct knowledge, skills and attitude" to carry out the new plan, which calls for:

Listening to patients and providing 7-day-a-week service

Focusing on outcomes covering mortality and quality for all surgical and medical specialties

Rewarding excellence by providing a quality premium for local clinical commissioning groups who secure quality improvement against NHS outcomes measures

Improving knowledge through standardized data sets and a new service, care.data, that will provide commissioners with timely and accurate data

Observers note that, even without new funding, CME/CPD providers will have new opportunities for needs assessment, programming and outcomes measurements that will enable the local Health and Wellbeing Boards to assist doctors and other professionals to accomplish the goals of the new plan. There is an incentive for industry to support such programs, if correct use of drugs and devices helps people go home from the hospital sooner, improves cancer survival rates, and reduces deaths from cardiovascular disease.

A related concern: Where do GPs fit in? Prof. Richard Roberts, president of Wonca (World Organization of Family Doctors), worries "that the practice changes being driven by NHS strategies ... will over time erode the foundation on which NHS is built: the therapeutic relationship between GP and patient. In aneditorial, he quotes a GP's observation: The greatest problem with the NHS is that major changes seem to occur about every 15 minutes without necessarily ... a compelling need."

How pharma plans to support CME in 2013

Pharmaceutical company respondents to a recent survey, most of whom have European or global responsibility, are ambivalent about spending levels on accredited continuing medical education this year, and, not surprisingly, expect third parties to have substantial roles in carrying out the CME.

The survey was conducted in the first quarter of 2013 by EPG Health Media, a UK research company, and focused on multichannel marketing in healthcare. When asked how they expect marketing spending for accredited CME to change between 2012 and 2013, 41% of respondents said they expect considerable or slight increase, and 24% expect considerable or slight decrease. Nonaccredited medical education fared about the same.

When asked what level of third-party support is required for accredited CME, 79% said considerable or moderate; 21% said none. Perhaps the latter were from the respondents from emerging markets! The biggest shift in spending patterns is predicted to be in the use of mobile apps and mobile optimization of online resources. Spending on print media and live conferences is expected to decline.

In a related survey conducted by Manhattan Research among physicians in 11 countries around the world, use of smartphones and tablets for professional purposes was quite high, 75% for the smartphones in Europe. Brazil, South Korea, Canada and China. And physicians everywhere seeking answers to clinical questions relied much more heavily on search engines and (nonpharma) websites than print journals.

CME providers worldwide seem to be moving more slowly than their audiences to make the most of mobile media for learning. What is your experience?

Does CME/CPD have a role in quality improvement?

More and more frequently, healthcare systems such as the NHS (see above) and the US under the new Affordable Care Act are moving toward standardization of diagnosis and treatment based on evidence, measured by data collected from physicians, other health professionals and hospitals. While government agencies, medical specialty societies and mass media are disseminating the standards, from our observation, the CME/CPD community appears to be little involved.

A study published in 2012 of more than 1000 physicians practicing in outpatient settings indicated that >5% of patients were difficult to diagnose. The chief reason cited was inadequate knowledge. In February of this year, the ABIM Foundation released a list of more than 130 tests and procedures that are commonly ordered but not always necessary -- and could cause undue harm. The new list was developed by 17 medical specialty societies through the Choosing Wisely campaign, which involves some 25 societies representing more than 725,000 physicians.

The ABIM Foundation has awarded funding, supplied by the Robert Wood Johnson Foundation, to 21 state medical societies, specialty societies and regional health collaboratives to help physicians and patients engage in conversations aimed at reducing unnecessary tests and procedures. Consumer Reports is aiding in educating the public.

Elsewhere, Sanofi has created a public-private partnership with the World Health Organization, the Centre of Disease Control and the Chinese Diabetes Society to promote career development of 500 diabetes experts to provide clinical and research training programs, with the goal of reaching 10,000 community and country doctors in China.

On the positive side, at the recent annual meeting of the Society for Academic CME, over 17 speakers highlighted the implications for the field of CME moving toward evidence-informed CME in practice, with key implications for quality and performance improvement. Dave Davis and Nancy Davis of the Assn. of American Medical Colleges introduced a new acronym -- Ae4Q (Aligning and Educating for Quality) -- and reviewed the progress of a nationwide effort to report on a cycle of improvement for academic health centers, utilizing 10 operational centers.

More on "freedom from commercial bias"

There's no end to the debate about the effect of commercial bias on physicians and their patient care as a result of industry funding of research and education, The latest contributions come from the European Board for Accreditation in Cardiology (EBAC) and 3 new studies on gifts from pharma to residents and medical students.

Writing in the Journal of European CME, Prof. Reinhard Griebenow and colleagues representing EBAC note that "most of the medical community has adopted the philosophy of evidence-based medicine as the basis for clinical decision making." However, they argue that most evidence comes from randomized clinical trials, 70-80% of which are funded by industry. Many of these must be supplemented by expert opinion or personal experiences, they say. "Therefore, every piece of evidence has to be examined as to whether it favors the maximization of profit or down-to-earth analysis of the risk-benefit ratio." Their conclusion: CME/CPD needs measures to ensure impartiality, honesty and transparency.

A report in BMJ examined the effects of medical school bans on gifts by pharma on prescribing practices of physicians after graduation. Those who attending no-gift schools were much less likely than a similar group from no-ban schools to prescribe 2 of 3 new drugs available to them.

Another study in Medical Care compared medical school graduates from 2008, after conflict-of-interest policies were established in US medical schools, to graduates from 2001. Findings: The 2008 graduates were less likely to prescribe heavily promoted brand-name antidepressants than the earlier graduates.

And finally, a study of a randomized sample of US medical students, appearing in Journal of General Internal Medicine, found that in spite of the bans, 1 in 3 first-year students and more than half of fourth-year students and residents reported receiving gifts from pharma. "The perception that industry interactions lead to bias was prevalent, but the belief that physicians receive valuable education through these interactions increased" over time, the authors stated.

MEETINGS 1 GAME 2 Global Accreditation 3 Doctors 2.0 4 IMMPA

1 The Global Alliance for Medical Education (GAME) holds its annual meeting this year in Barcelona, Spain, from June 9-11. The cutting-edge theme is "The Next Level: The Necessary Interaction of Outcomes, Instructional Design, and Assessment". To learn more and register, clickhere.

2 The Accreditation Council for Continuing Medical Education (ACCME) and the Royal College of Physicians and Surgeons of Canada have created the International Academy for CPD Accreditation to provide interchange among those involved in existing or future accreditation systems around the world. The inaugural meeting will be by webinar May 23. To learn more, click here.

3 Doctors 2.0 & You will be held in Paris June 6-7, an international conference devoted to the understanding of how physicians use new technologies, Web 2.0 tools and social media to communicate with colleagues, patients, payers, pharmaceutical companies and public agencies. The conference will feature best practices for social media and apps in 17 specific disease conditions. To learn more, click here.

4 The annual InforMed conference sponsored by the International Medical Meeting Professionals Assn. will be held May 21-22 in Cleveland, Ohio. The agenda includes a major focus on physician payment sunshine acts around the world and other international compliance updates. To learn more, click here.

WMGS News

WentzMiller principals and associates have been consulting on marketing directions in the US and abroad with 2 US companies: (1) VitalSims, a healthcare education company delivering accredited learning simulations using the latest accelerated-learning technology. (2) Scientiae, whose live and online activities encourage participants to apply learned knowledge and skills to improve patient outcomes.

We would be pleased to discuss your needs and opportunities, and how we can help fulfill them. Call or write Barbara Pritchard, Principal, at 203.869.2717, or BPritch887@aol.com.

Our Mission: To enable clients to better understand and leverage the changing trends in International Continuing Health Education for the purpose of generating improved results from their programs & initiatives

Transparency is the"hot" word in CME/CPD, in the US, Europe and elsewhere in the world. The implication is that relationships between doctors and pharmaceutical funders of CME have been hidden behind seven veils of secrecy for years and now need to be disclosed. We raise the questions of to whom, and will it make a difference in the quality and delivery of continuing medical education.

Sunshine for whom: doctors, industry, public?

The long-awaited final rule for implementation of the U.S. Physician Payment Sunshine Act was released in February: Starting August 1, pharmaceutical, device and medical supply companies must report all transfers of value over $10 to physicians and teaching hospitals. Lest you are not worried because you are from outside the U.S., don't get comfortable. A recent survey at a pharma conference indicated that every country in the world will have some sort of reporting requirements within 5 years.

In brief, the U.S. act does make an exception for speakers at CME events if the event meets standards of the Accreditation Council for CME (ACCME) or American Medical Assn. (AMA). This means the CME provider, not the company, pays the speakers and monitors the fair balance of the contents. But if a company representative provides lunch to doctors attending a hospital educational program, that must be reported.

The Center for Medicare and Medicaid Services (CMS), which will administer the program, estimates first-year total costs to government, doctors, hospitals and industry at $269 million, and $180 million thereafter. But CMS admits to being unable to estimate the monetary value of the act.

We wonder who will benefit. The sun will shine on thousands of transactions of little value, transactions that are unlikely to influence doctors' prescribing habits or the health of patients. It's true that certain abuses will be exposed to light, when a physician or hospital receives tens or hundreds of thousands of dollars for providing minor consulting or research services, or major discounts on drugs or devices. Here's a quick prediction of effects:

Industry will be forced to collect and organize data from local and regional representatives to fit the CMS format, but failure to report will bring what are minimal fines

Doctors will nervously accept (or forego) simple meals in the hospital or office, minor gifts, etc. -- and will periodically check their listing in the Sunshine site to see what has been reported

Patients are unlikely to know about the site, and to visit it with anything but curiosity

Government will monitor the site seeking evidence of fraud and abuse by industry, but seldom to bring action against doctors

The media will enjoy publicizing "greedy" doctors in their area

Healthcare of the public: Will there be a benefit?

France is awaiting final rules for its "LeSunshine Act", passed in 2011. In other countries, including Japan, Australia, Slovakia and the UK, industry codes call for some level of reporting either to government websites or the industry's own site. Global companies are concerned about how to coordinate all reporting activities. Will CME improve as a result of "transparency"?

Now, a global compendium of rules

A new resource may become the way for global pharma to keep up with changing sunshine reporting requirements: The Society for Worldwide Medical Exchange (SWME) has released "The Red Book for Medical Meetings", an online and print compendium of pharmaceutical and CME rules for more than 100 countries. Dr. Alfonso Negri, Secretary General of the Rome CME-CPD Group (and a WentzMiller associate), supervised collection of data from existing sources.

SWME doesn't guarantee validity of data, but is hoping that, like Wikipedia, subscribers will provide corrections and updates. The resource, which offers the first global effort toward organizing this critical information, costs $380 for an annual subscription.

CME opportunities in Saudi Arabia

Saudi Arabia is well positioned to embark on online CME, says Dr. Adnan Alwadie of King Fahad Medical City, Riyadh, in an article in the journal of the International Society for Performance Improvement. CME is mandatory and is conducted mostly through live programs organized by large hospitals, universities or scientific societies. But many healthcare professionals in smaller cities and rural areas have fewer CME opportunities and provide lower quality services, he notes.

The population of Saudi Arabia, the largest country in the Mideast, has grown rapidly to more than 27 million. The country faces the same healthcare issues as many Western countries, says an article in PharmaVOICE: increase in chronic diseases and longer life expectancy. The government share of healthcare spending is 67%, and the private sector 33%, mostly in cities and large towns. Primary care is provided through some 2,000 government clinics; patients can then be referred to secondary or tertiary care hospitals when needed.

The PharmaVOICE article quotes a market analyst as saying: "Diabetes, hypertension and hyperlipidemia are now highly prevalent," with a diabetes rate some 3 times the international rate. There are opportunities for CME focused not only on diagnosis and treatment but also on prevention. For example, one estimate indicates that 30% of Saudi males are obese.

Dr. Alwadie suggests that the Saudi Ministry of Health should "focus on improving the quality of services by acknowledging deficiencies and scientifically approaching them," and should consider establishing a center to provide online CME to healthcare providers in all parts of the country, as well as a system for monitoring and tracking CME programs.

CME in Europe: Gains and frustrations

Dr. Edwin Borman, Secretary General of the Union of European Medical Specialties (UEMS), sees the new UEMS requirements for CME accreditation as a "revolutionary change" that will bring up the general standard of good CME. While not disagreeing, there are voices in Europe who would like to see more done to improve and standardize CME quality and process.

In a series of interviews in pharmaphorum online, three voices are heard:

Dr. Borman believes that CME in Europe has changed profoundly in the past 20 years, but now needs to aim at improving quality of care, assessing learners' needs better and making events more interesting and interactive

Eva Thalmann, med ed leader for Janssen in Europe, agrees that CME has improved but is still concerned that it is too fragmented, with differing requirements by country and medical society

Dr. Robin Stevenson, editor of the Journal of European CME, believes that while there has been a positive shift to more interactive teaching, Europe won't have much chance for unified high standards until the system moves to provider accreditation

A common provider accreditation system might alleviate the fragmentation, but doesn't appear to be on the horizon soon. Italy has adopted this approach rather than program accreditation but it is too early to tell if the quality of CME programs has improved. No other country nor specialty accreditation board has moved to make a change. nor has UEMS, which could lead if there were enough support from the European specialty societies who could become the major accredited providers.

CME in Asia still "in its infancy"

Lisa Sullivan, managing director of In Vivo Communications in Australia and Singapore (and a WentzMiller associate), says that "the CME world in Asia is very different to the developed world and is still in its infancy," according to an interview in pharmaphorum. "Most Asians still prefer to meet together and be lectured to," reflecting the hierarchical nature of learning in medical school.

Other limiting factors affecting the growth of CME in Asia, she notes, include:

Language. "Doctors from Korea, China, Vietnam and Indonesia are more likely to interact ... in their own language due to their concerns of their 'poor' English"

Online learning. "There is a limited amount of eduction online and it tends to be focused more at primary than secondary care"

Accreditation. "Accredited CME is still not a requirement in many countries," limiting commitment to advanced principles of CME

Outcomes measurement. "Asia really needs to step up and consider this imperative in their CME development and delivery"

Most CME in Asia is developed by universities, hospitals and medical associations, and pharma funding is growing rapidly, frequently in collaboration with the providers. "If you're in the business of CME development and delivery," Sullivan concludes, "come to Asia with your eyes open ... it is a lot of hard work!"

Some of Sullivan's observations are borne out in a recent study of Chinese GP training needs in preventing and managing hypertension. In an online article, the authors note that "continuing education is urgently needed to ensure that physicians in general practice are aware of and adhere to the national hypertension guidelines." The survey showed that the accuracy rate of hypertension prevention knowledge was only 49%, and while most GPs were willing to attend training courses regularly, they wanted expert lectures on treatment.

1 The American Medical Assn. (AMA) and the Royal College of Physicians and Surgeons of Canada (RCPSC) have renewed their reciprocal CME credit system for 6 years. "Select activities" approved for RCPSC credit are eligible for AMA Category 1 credit, including live group learning, web activities, self-assessment programs and simulation activities.

2 M3, a Sony-owned Japanese conglomerate, has announced that its Networks in Health will now partner with Medcenter of Argentina to extend its content reach to Spain, Portugal and Latin America. Networks in Health claims more than a million members worldwide, who have access to journal aggregation, conference coverage and pharma information. Medcenter claims a network of 480,000 physicians.

3 Policy makers and payers are enthusiastic about pay-for-performance, but a recent study meant to show how incentives improve quality among lower-performing U.S. hospitals failed to do so, instead producing the most improvement in higher-performing hospitals. In another study, improvements in process-of-care in UK family practices were the result of a pay-for-performance program, with outcomes improvement following.

WMGS Associate News

We are pleased to announce that our Associate, Dr. Edwin Borman, will assume the role of medical director of the Shrewsbury and Telford Hospital NHS Trust in April. Dr Borman has been consultant anesthetist at University Hospitals of Coventry and Warwickshire in the UK. He is also secretary general of the European Union of Medical Specialists. We wish him well in his new post.

We are also pleased to welcome Lisa Sullivan to the ranks of WMGS associates, bringing our consulting firm expertise in CME in the vast region of Asia. Ms. Sullivan is managing director of In Vivo Communications, with offices in Australia and Singapore. Her organization specializes in the design, development and implementation of educational programs for healthcare professionals. She is board member of the Global Alliance for Medical Education (GAME).

Our Mission: To enable clients to better understand and leverage the changing trends in International Continuing Health Education for the purpose of generating improved results from their programs & initiatives

CME professionals benefit from gaining a perspective on global healthcare. So we feature in this issue a couple of European analyses, on population healthcare status and on physician views on CME. In addition, we offer a summary of mega-trends that will affect the healthcare industry, a perspective on China and a check on the performance of global pharma. What trends have we missed?

Europe: Health improves, but will it decline?

European countries have achieved major gains in population health, but there are fears that the economic crisis may take a toll on people's health in the years to come, says a recent reportfrom the Organisation for Economic Co-operation and Development (OECD). Highlights of the report:

Life expectancy at birth in the EU has increased to 79, with France at 85 for women, Sweden at 79.4 for men

Life expectancy at 65 has increased to 16.5 years for men, 20.1 for women, posing an increasing burden for the healthcare system

Smoking and alcohol consumption have fallen but obesity is on the rise, as are several chronic diseases, including diabetes, asthma and dementia

While the number of doctors per capita has increased, so has the percentage of specialists, leading to a concern about access to primary care

Hospital mortality rates for heart attack and stroke have fallen dramatically, but there are too many admissions for uncontrolled diabetes

EU countries cut health spending per capita by 0.6% in 2010, after annual increases of 4.6%, putting a bigger cost on households to purchase care

As one example, the severe economic crisis in Spain is already taking a toll on healthcare services, including CME. Thousands marched in Madrid in 2012 to protest healthcare austerity measures, reported PMLiVE. "Certain sick people must now clamor to get treated," said one gastroenterologist. Some pharma companies have suspended sales of drugs to hospitals who can't pay because the government is not paying them. The universal healthcare system is under fire. Patient co-pays are going up. And pharma funding for CME is declining, reports WMGS associate Dr. Alex Ramos.

How will these trends affect CME throughout the EU? Is is likely that government support of CME will diminish? Will pharma in all countries spend less as government reimbursement rates are cut? Will physicians divert their individual spending to more pressing household needs? Your opinions are welcome; send to lew@wentzmiller.org.

European CME: Trending away from congresses to online

Participation by European healthcare professionals (HCPs) in international conferences is dropping, but increasing in online CME and smaller live workshops and courses, according to a recent surveyconducted by EPG Health Media.Primary reason: Cost. Secondary reason: Lack of time. Here are survey highlights:

CME is compulsory for 62% of respondents, 26% take more than required, and 33% participate even when not required

International conferences and printed CME have less impact on improved patient outcomes than other forms of CME

89% of respondents participate in online CME, even when not accepted for credits; 50% take more than 2 years ago

Cost and time factors influence participation far more than educational content or outcomes

While 39% say pharma funded CME is less credible and may be biased, most want pharma to fund more

While 50% of respondents believe credits are important, almost the same number have difficulty in learning whether an activity in accredited in their countries

A majority of respondents do not believe that most CME meets their specific needs or directly impacts their practices

What are the implications of the survey findings for the future? The authors suggest that a more standardized and transparent structure for accredited EU CME is needed, and that issues of credibility and trust should be addressed. In addition, it appears to us that better needs assessment, based on targeted improvements in patient outcomes, would lead to more effective CME.

One postscript: While a new survey by Manhattan Research found that 72% of European online consumers age 18 or over use the social web for health, few HCP respondents to the EPG study use social media to keep informed about CME activities.

Healthcare industry mega-trends and pharma trends in 2013

In a 6-minute video, Paul Keckley of the Deloitte Center for Health Solutions describes 7 mega-trends that will influence the healthcare industry in 2013:

Demanding demographics: The population is older and more diverse, with stronger desire to have healthier lifestyles

Strategic globalization: Medical tourism is on the rise; US share of global pharma sales will drop to 31% by 2015

Unconstrained connectivity: Consumers want control over access to their electronic medical records

Constrained resources: The healthcare industry faces cutbacks in government payments, has a shortage of talent and difficulty in accessing capital

Accelerated consolidation: To achieve sustainability in the face of a fragmented system, there will be more consolidations

Big data: The new direction is to translate that data into relevant information. The results will separate winners from losers

Consumer discontent: Many people view healthcare as underperforming due to waste and inefficiency

After a decade of under-performance, primarily due to patent expiries, the global pharmaceutical industry is poised for a comeback, suggests the Financial Times. The industry still faces shrinking health budgets and unproductive research & development spending. But companies still generate lots of cash, are gaining in emerging markets -- now accounting for almost as much as Europe -- and have a high number of drugs in the pipeline.

Healthcare in China: Opportunities and roadblocks

China's healthcare sector is expanding at "an astonishing rate," says a McKinsey Quarterly report, going from $357 billion in 2011 to a projected $1 trillion in 2020. So there are many opportunities for pharmaceutical companies, medical products and consumer health companies -- and by inference, CME providers. But, warns the report, there are some negatives: pressures on pricing and the rise of local champions.

Positives include the economic and demographic trends, further healthcare reform to provide universal coverage and improvements in infrastructure, including doubling the share of private sector hospitals to 20% by 2015. Even more important is the government goal to develop a primary-care infrastructure that includes community health centers and stations, combined with county hospitals, township health centers and village clinics. On-the-job training of primary care physicians is underway. Over years, this should change the attitudes of patients who now visit the best hospitals in the largest cities, ignoring grassroots facilities.

Unfortunately, reform comes with barriers, says a Financial Times report, creating further division between the haves and the have-nots in the population. Some of the barriers:

Spiraling costs, for example, leading the city of Shanghai to cap yearly increases in funding

Over-prescription of drugs, coupled with underdiagnosis of cancer, depression and respiratory illness

Serious shortages of well-trained professionals

Rampant corruption, including bribes to physicians to overprescribe

Private hospitals' refusal to take public health insurance

In the midst of this rapid though erratic growth lie opportunities for CME providers, perhaps best accomplished through joint ventures with Chinese organizations, in particular medical schools. Some such efforts are already underway in undergraduate medical education, but little has been accomplished in the CME field. In addition, there are a handful of Chinese medical education companies, some of whom might be open to joint efforts. To our knowledge, at least one North American med ed company has already started to operate in China, with some assistance from a division of the Chinese Health Ministry.

Key to CME excellence: NOT needs assessment!

The European CME Forum was challenged last November in Amsterdam by Jonas Nordquist PhD of the Karolinska Institute, Sweden, when he told the audience that needs assessment is NOT the missing link to educational excellence in CME/CPD. The missing link, he said, is good educational design, design that is learning oriented, active, participant centered and includes dialogue.

His presentation, and that of many other speakers, can be downloaded at the Forum site. In a way, Dr. Eamann Breatnach of the European Board of Radiology, came around to defending the needs assessment process when he described how the Faculty of Radiologists works with the Irish Medical Council to ensure that radiologists are maintaining their competence. Part of the process includes audit to analyze patient and/or department outcomes. Celine Carrera outlined new approaches to CME at the European Society of Cardiology, and Dr. Colette Andree did the same for the World Headache Alliance. ELearning was also a popular topic.

1 The long-awaited regulations to implement the Physician Payment Sunshine Act in the U.S. are stuck in the White House, reports Policy and Medicine Update. There appears to be a battle between the American Medical Assn., which wants to exempt CME payments to physicians, and consumer advocates who object to this.

2 Canada's single payer healthcare system provides higher quality at a fraction of the cost, compared to the U.S. Medicare system. That's the conclusion of 2 Harvard professors in a letter in Archives of Internal Medicine. Major reasons include a much higher ratio of primary care physicians and much lower administrative costs in Canada, where there are no health insurance companies in the middle.

3 By next summer, those who plan healthcare meetings can become certified as Certified Healthcare Meeting Professionals. The idea originated with the International Medical Meetings Professionals Assn., which says its members "face the stiffest and most complex government regulations of any industry".

WMGS welcomes a new associate

We are proud that Alex Ramos MD, MEd, has joined the ranks of WMGS associates to represent Spain. Dr. Ramos has many years of experience in the field, not only in Spain but also in Europe. He is currently Director of the CME Department - Centre of Studies, and Director of the Accreditation Office of the Official Medical Assn. of Barcelona (College of Physicians).

WentzMiller Global Services works with organizations that seek global expansion and growth of their continuing health education activities. Our mission is to enable clients to better understand and leverage the changing trends for the purpose of generating improved results from their programs and initiatives. Contact us at lew@wentzmiller.org, 203-662-9690, or bpritch887@aol.com, 203-869-2717.

SEARCHING THIS SITE: PRESS CONTROL F AND ENTER YOUR SEARCH TERM. YOU CAN SEARCH ANY SECTION LISTED TO THE LEFT, ONE SECTION AT A TIME.